Is It Time To Give Palliative Care To Patients With Newly Diagnosed Cancer?

Is It Time To Give Palliative Care To Patients With Newly Diagnosed Cancer?

There is ample evidence that palliative care interventions can improve quality of life and ease symptom burden for patients with advanced cancer who are expected to have a short life expectancy. However, fewer studies have addressed the role of palliative care early in the course of disease for patients who are newly diagnosed with advanced cancers. The findings of a new study of palliative care interventions in patients with newly diagnosed advanced lung and gastrointestinal cancers was the focus of a presentation during the June 5 Patient and Survivor Care Oral Abstract Session (Abstract 10003). A poster in the June 6 Patient and Survivor Care Poster Session evaluated the effects that these interventions had on the caregivers of the patients in the study (Abstract 10131).

Palliative Care in Patients With Newly Diagnosed Advanced Cancer

To explore the effects of early palliative care care, 350 patients who had been diagnosed with incurable lung cancer or noncolorectal gastrointestinal (GI) cancer within the past 8 weeks were randomly assigned to receive early palliative care integrated with oncology care or oncology care alone. Patients in the early palliative care group met or spoke on the phone with a palliative care clinician at least once a month, and those in the oncology care–alone group could receive palliative care if the patient, family member, or clinician requested it.

To assess the impact of palliative care on caregivers, patients were asked which family member or friend would be supporting them through their care and accompanying them to clinic visits, and these caregivers were asked to participate. A total of 275 caregivers agreed and enrolled for this portion of the trial.

The palliative care clinician documented the topics that were discussed during each palliative care session, some of which focused on understanding the illness, treatment decisions, and advanced care planning. The topics most commonly discussed were symptoms, particularly pain and fatigue, and coping, such as redirecting hope, which made up 74.7% and 70.2% of the conversations, respectively.

Patients were evaluated using a number of measurements at 12 and 24 weeks after joining the study, including the Functional Assessment of Cancer Therapy-G (FACT-G), which assessed their quality of life over the last week. Patient mood was assessed using the Patient Health Questionnaire-9 (PHQ-9), which incorporated Diagnostic and Statistical Manual of Mental Disorders criteria for depression, and the Hospital Anxiety and Depression Scale.

In the lung cancer cohort, patients in the palliative care group were found to have significantly improved FACT-G and PHQ-9 scores compared with the oncology care–alone group at both 12 and 24 weeks. In contrast, patients with noncolorectal GI cancer who received palliative care were not found to have significantly better outcomes in these measures than the control group at either time point, with the exception of improved FACT-G scores in the palliative care group at 24 weeks.

Dr. Jennifer Temel

Participants in the study were asked questions to gage their goals for treatment, interest in understanding the disease, and level of communication. Patients in the two groups were similarly likely to say their primary goal for treatment was to be cured or to extend life as much as possible despite more pain and discomfort. However, the patients in the palliative care group were significantly more likely than those in the control group to report wanting to make decisions about treatment, coping with the disease, and discussing their wishes for end of life.

“Palliative care should be tailored to the illness trajectory and needs of patients with advanced cancer,” said Jennifer S. Temel, MD, Massachusetts General Hospital, during her presentation of the findings of the randomized trial. “A one-size-fits-all approach may not be the best strategy for providing quality care for patients with newly diagnosed advanced cancer.”

In the discussion period, Dr. Temel addressed questions about why palliative care in patients with noncolorectal GI cancer was not associated with improved quality of life at 12 weeks and with mood at 12 and 24 weeks. Although it is not clear, Dr. Temel suggested that the lack of outcomes could be because the noncolorectal GI cancer cohort was not planned at the outset of the trial, and, as a result, there could have been differences between the palliative care and control groups.

Could Palliative Care Improve Outcomes Among Caregivers?

The question of whether integrating palliative care in the treatment of patients with newly diagnosed advanced cancer affects caregivers’ outcomes has not thoroughly been explored. “[Caregivers] provide a critical role in providing care for their loved ones through their illness trajectory, and that can result in substantial caregiving burden that negatively impacts [their] quality of life and mood,” Areej El-Jawahri, MD, of Massachusetts General Hospital, said in a press interview with ASCO in advance of the Annual Meeting. Dr. El-Jawahri presented the poster that discussed the effects of the palliative care intervention on the patients’ caregivers (Abstract 10131).

Dr. El-Jawahri reported that the caregivers accompanied patients in the palliative care group to about 40% of their palliative care visits. In most cases, the caregiver was a family member, such as their partner, a sibling, child, or friend.

Using the same measurements as for the patient participants, Dr. El-Jawahri and her colleagues assessed quality of life and depression among family caregivers. The family caregivers of patients in the palliative care group were found to have higher quality of life measures, particularly in areas of perceived social support, social functioning, and overall wellbeing compared with those caring for patients in the control group, Dr. El-Jawahri said.

This portion of the study was not adequately powered to detect differences between the two groups of family caregivers, Dr. El-Jawahri noted. However, the fact that the researchers are still observing differences is impressive, she said.

Dr. Arif Kamal

Dr. El-Jawahri and her colleagues would like to conduct analyses to explore whether the possible improvements among family caregivers is being mediated by the improvements in patient outcomes. In return, if family caregivers are feeling better, they could help patients feel better. “Improving family caregivers’ outcomes can result in a positive feedback loop that further enhances patient care,” Dr. El-Jawahri said.

Patients Want Palliative Care; How Can They Get It?

There is a growing awareness of the patient desire for palliative care, said Arif Kamal, MD, MBA, MHS, of Duke Cancer Institute, in his discussion period. According to Dr. Kamal, one of several cases to this point is the fact that the link between patient perceptions of quality of care, value, and reimbursement are now closely connected with the delivery of palliative care in a growing population of patients with cancer. In fact, receiving supportive care often ranks higher in patient surveys than measures that often get more attention, such as U.S. News & World Report rankings.

Now that the importance of palliative care to patients is clear, the focus has shifted to how to deliver this care. There are many questions and challenges in this regard. It is not clear how long and how often palliative care should be provided, although most studies, including Dr. Temel’s, used monthly sessions. A serious challenge is the lack of clinicians trained to offer palliative care to their patients.

Research is highlighting the fact that not all patients with cancer will respond in the same way to palliative care. An example of this is the finding in Dr. Temel’s study that patients with GI cancer did not seem to receive the same benefits from palliative care as patients with lung cancer. “We know that not all cancers are the same, we know that from a precision medicine perspective, and now we can start to see that from a palliative care perspective,” Dr. Kamal said.